Basic Information
| Provider Information | |||||||||
| NPI: | 1841239746 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TANN | ||||||||
| FirstName: | MARK | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 N SHADELAND AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462194959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 714 N SENATE AVE | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462023763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177156402 | ||||||||
| FaxNumber: | 3177156415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 03/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0902X | 01056509A | IN | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy | 2085R0202X | 01056509A | IN | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0904X | 01056509A | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00195774 | 01 | IN | RAILROAD MEDICARE | OTHER | 200406300 | 05 | IN | MEDICAID | P00108643 | 01 | IN | RAIL ROAD MEDICARE | OTHER |